Wednesday, May 11, 2016

Nursing, and the Crocodile of Time

They come in
ambulances, they come in vans, and they come in crawling, drunken, and puking
in pans.

They come with strokes,
overdoses, injuries and pain.

They fall and get
fractures from ladders, and many other things that really don’t matter.

They demand the best,
the most, the quickest, for free - and yet, when needed, they can’t even pee.

They injure themselves in so many ways; too
many to count as there are not enough days.

It is sad really, the
condition of people - so grand a species, that finds everything so lethal.

They will not stop
coming, these humans with brains, they just need immediate relief of all of
their pains.

So in the end, there
really is nothing to do; drugs, seatbelts, gravity and rape, learn they will
not, these humans with brains; as we will patch them up good, send them back where
they stood, and wait for their return, for it is our livelihood.

An ED is a stressful place, quite different than any other
work environment, outside of, perhaps, active duty military, paramedics, and police. We, the
nurses, are stretched to accomplish all manner of tasks, in the quickest way,
without an error, with the least amount of cost, with the most skill, capturing
all of the data, with the fewest steps, and with an overwhelmingly cheery
demeanor – all day, all night, all year long.

Every second counts, but not only for patient care, speed of
service delivery, electronic chart manipulation, management benchmarks and
facility goals – but for time itself. Seconds add up to minutes, and minutes to
hours. It is the basis of all science. And so, every second lost to a missed
step, a mishandled medication, a broken printer, another trip with a patient to
the bathroom, is time compounded. Add to all of the thousands of tasks
performed in each 12-hour shift, another 2.8-second chart entry, another
software screen to navigate, another step in any process. Without taking away precious
seconds from another task, this will all end up lengthening the day.

The Massachusetts Institute of Technology (MIT) produced a
wonderful study of why traffic comes to a complete stop on the freeway for no
apparent reason. The results show that if any one vehicle even taps the brakes
for a half second, producing just a quick glow of the brake lights and a drop
in speed of an infinitesimal amount, that this action is carried on behind that
vehicle - each one driver lengthening the reaction until, one mile away, you
are at a standstill. Apply this to any task in a busy ED, such as a printer
that won’t function. Such a delay (the glow of a brake light) means you have to
re-print a document by altering the print options, checking for a signal,
checking the paper supply, changing the default location, etc. Eventually you
will walk to another room, or location, and try this same procedure with a
different terminal, and a different printer. This simple, yet overlooked delay,
has prolonged the medication administration for another patient by 2.4 minutes.
On the surface this time seems short, yet compounded with hundreds of others –
you are sitting in your stalled car, in gridlock, listening to death metal
pouring out of a nearby Pinto.

In addition to the thousands of tiny delays, is the fact
that no one person is responsible for eliminating or repairing these delays.
This magical fix-it person is actually – you. Yes, the nurse who is actively
engaged in the time delay is also the one responsible for finding a solution
for the problem. A repair can be something like signing into a ‘work order’
software program and navigating through various fields for hardware repair, resetting
all of the default printer preferences – or, worse yet, a time consuming
telephone call to some outsourced IT call center, to someone who has no
investment in your situation, and is not concerned about the passage of time in
any way.

A recent study from Michigan
State University in East Lansing, shows that on average, an interruption in a
task of only 2.8 seconds leads to a 15 minute delay in completing that task.
Think of how many times you have walked toward a patient room, only to be
diverted by a call light from another room, or the time you go to the
electronic medication dispenser, forget the patients name, and then have to go
find a computer, log in, and search. Compound all of these by 100 for a 12-hour
shift, and it is no wonder that the length of stay (LOS) is creeping up again.
As the complexity of a system grows, so does the potential for delays. And with
people only employed to add to the complexity, and not to streamline it, there
is no end in sight for the difficulties.

Concerning the hospital LOS, it
was decreasing ten years ago, and everyone was quite proud. But as the
population has grown and aged, rampant drug use has increased, care has become
intolerably expensive, and the computer systems that bind it all together have
become more fractured – the length of stay has risen.

Antoine de Saint-Exupery wrote,
“A designer knows he has achieved
perfection not when there is nothing left to add, but when there is nothing
left to take away”. Any experienced computer programmer in the medical
profession has this same St. Exupery ability; to create a streamlined
user-friendly platform that is modern, and simple, and attains the goals set
forth by the care. Think Amazon and Google – two of the worlds most
user-friendly and lucrative businesses on earth. They are simple to navigate,
never go down for upgrades, and are super efficient. If only charting an
intubation in the EMR was as simple as buying a vibrator on Amazon. Oh the
glory!

However, by a series of
unfortunate events, we the Emergency Department nurses (as well as the floor
nursing staff) have been burdened with an Electronic Medical Record (EMR) that
is nothing more than ten thousand loose parts flying in formation. I can stream
live color video from Saturn on my iPhone, and yet our $390 million dollar EMR cannot
spellcheck or convert pounds to kilograms, doesn’t know that penicillin is a
drug or an apple is a food. Every day within the EMR there is a tweak, or a
change, or a malfunction, or a discovery, all adding tiny little bits of time
to the day, all reverse-engineered at the sacrifice of timely patient care.

So, with time being finite, and
the fact that patient severity and volumes have increased - and with a limited
corporate budget, choke holds on staffing, and with the phrase ‘multi-tasking’
becoming the invisible phrase between each line of a mission statement –all of
these measurable factors are pushing quality to its edge.

A study published
in The Lancet in 2014 found that an increase in a nurse’s
workload by one patient increased the likelihood of a patient in that hospital
dying by 7 percent. Staffing ratios
also appear to reduce the rate of readmissions, many of which are preventable
and constitute a significant cost for hospitals. The Affordable Care Act (ACA)
sets penalties for hospitals with high rates of readmissions. In one 2013
study researchers at the University of Pennsylvania School of Nursing
examined data from hospitals across the U.S. and found that those with higher
staffing ratios had 25 percent lower odds of being penalized under the ACA for
excessive readmissions than ones with lower staffing ratios but otherwise
similar conditions.

Staffing ratios for the Emergency Department are generally
viewed upon as blasphemy by management. It tastes like freezer-burned brussel
sprouts to the well-educated palates of higher offices, and it also affects
corporate earnings and creates shareholder distain. So, even though the
evidence supports staffing ratios, it is not likely to occur anytime soon. So,
with an ever-increasing population of very ill humans, computerized charting
that bludgeons to death even the most digital savant, and an employing host
incapable of understanding the trials of its workers – the future is bleak my
friend.

Time is what is killing the nursing profession - or, to be
precise, the lack of time.

We have a nurse in our Emergency department, and I will call her
Grace. Every department has one - a
true to life, dyed in the wool, for real nurse. She holds patients hands,
believes their crazy stories, looks into their eyes, hugs them and cries with
them, even spends her own money on them. She walks them out to their car, she
thinks about them at night, she…cares. There is nothing in the electronic
record that reflects her care – nothing. There is no check box for ‘care’, or
‘concern’, or ‘love’. But, she is measured on the same scale as the rest of the
staff: 500 data points per trauma patient, LOS is too long, time to pain meds
is unacceptable, CMS benchmarks are insufficient, medication scanning is
sub-par, etc. Grace decided to use her time for patient care instead of bowing before the graven idols of statistical data
– and she will be punished for it. However, is this the nurse you want taking care
of your daughter or mother - or would you prefer the nurse that excels in
haste.

So how does good direct patient care look to the billers and
codes of a profitable organization? The more boxes checked, lines filled in,
tabs completed, tasks timed, and redundant research based data entered (all
timed to organizational and national benchmarks of speed) – the greater the
patient bill, the greater the reimbursement, the greater the ability to pay staff and procure
new technology. How does one code for Grace’s level care - you can’t. Nursing
has its flaws, but intelligence is not one of them. We all know that taking
care of the EMR, even with all of its defects, is better for the bottom line
than actual bedside care. The EMR makes money – bedside care does not.

A recent 3-year longitudinal study shows, “that nurses spend about
37% of their time with patients.
Work patterns were increasingly fragmented with rapid changes between tasks of
short length. Interruptions were modest but their substantial
over-representation among medication tasks raises potential safety concerns. There
was no evidence of an increase in team-based, multi-disciplinary care. Over
time nurses spent significantly less time talking with colleagues and more time
alone.” -Westbrook, Open Access.

Additionally,
a new study, published in April of 2016 by Johns Hopkins, is claiming that
complications from medical errors in hospitals are now the third leading cause
of death behind heart disease and cancer. This is a bold statement, and yet it
describes the environment where, being over tasked and understaffed, it is
almost anticipated. Various entities that hold great stakes in these findings –
particularly, the insurance companies, the government, and pharmaceutical
lobbyists - will dissect this study with vigor, most likely adding new forms to
the already fragmented EMR, adding steps for giving medications, perhaps even
an official “time out” with a co-worker as witness, before even a Tylenol can
be given. Again – time.

Many new nurses are overwhelmed at the ability to capture time,
divide it, and dole it out in safe increments, especially in an active almost
battlefield style atmosphere. Multi-tasking is a term that is pushed down the gullets
of bedside nurses by all of administration. It is a clichéd term, loosely
expressing the ‘apparent human ability to perform
more than one task, or activity, over a short period of time. Multitasking,
however, can result in time wasted due to humancontext switchingand apparently causing more errors due to insufficientattention’. I for one do not want my orthopedic
surgeon multi-tasking.

This relentless battle for time could be pushing nurses into new
directions; instead of hand-to-hand combat with tasks and time, why not join a
new legion - where time and direct patient care have been replaced by the
ability to create time itself. In 2015, the burgeoning field of nurse
informatics now has an average salary of just over $100,000. These are seasoned
nurses who have either ‘been there, done
that’, or are fresh out of school, intent on good money without the direct exposure
to the various illnesses and maladies of humans. Lets face it – informatics is
where the money is right now, not bedside nursing. These jobs, however, are as scarce
as Bigfoot sightings. But as technology slowly consumes almost all of a nurse’s
time, there will be many more openings in the informatics galaxy.

We, as nurses, have twelve hours to produce as much profit as we
can for the institution. We, as nurses, all know where our paychecks and
retirement plans come from, and we understand the inner workings of the
healthcare system and all of its governmental tentacles. We are the data entry
specialists. We have 720 chaotic minutes to produce 10-20 complete medical
records, documenting up to 250 items per patient encounter, in real time, with
good outcomes. We are not measured in care, but in speed. We are not measured
in interactions and conversations, but in volume of data points. We are only measured by the electronic medial
record. “If it wasn’t charted – it wasn’t done” is the maxim we live by. Medical
care is a huge business – huge! The amount we spend on health care every year has grown from
$75 billion in 1980 to nearly $500 billion today. If this rate continues, by
the year 2020, we will be spending 40 cents of every dollar we make on health
care.

So, there you have it. A finite amount of time for patient care,
defined by economics and computer programmers - with an infinite range of
potential challenges, defined by human nature and chaos. Emergency care could
be described as a fractal -an expanding wave of symmetrical duties; a spiral of
events in time, always compounding, never ending. Just like the ticking crocodile in Peter Pan, time is
following us all.

The only real
solution is to manage, as best we can, the time we are given - and hope for
reasonable, noble changes from above. Changes such as; single task, simplify,
create practical patient ratios, eliminate redundancy, hire adequate staff, hire
the correct staff, streamline documentation, employ shift based problem
solvers, use new technology only if it is beneficial, base care on quality not
quantity, compensate experience, take pride in effort, talk with each other,
and always do the right thing – the first time.

About Me

I travel as much as I can afford, and afford much less than I desire. The rewards, however, are priceless.Watching sunlight creep across a red desert valley, glitter through an emerald forest, or transform a desolate expanse of ice and snow into a wrinkled lavender blanket is much more than these photographs can provide. They are simply tiny slices of time, a memory; a single moment of the landscape that will never be the same again.